Direct primary care (DPC) is a new way for patients to access and pay for health care.
Under DPC agreements, patients/consumers pay a fixed monthly fee which gives patients access to certain medical services from dedicated DPC practices.
A key feature of DPC is that consumers’ claims are not sent to insurance providers. Since DPC is not technically insurance, it is often paired with a high-deductible health plan (HDHP) or a health savings account (HSA) to cover additional needs that are outside the scope of the DPC arrangement.
Currently, Wisconsin law does not specify how DPC should be regulated, the scope of services DPC providers may offer, how DPC differs from health insurance or whether DPC practices can bill Medicaid.
Arguments For and Against DPC
DPC has been promoted as a way for consumers to save money on primary care services, since there are usually no co-pays or deductibles. Furthermore, by not accepting insurance payments, DPC providers avoid the overhead and complexity of dealing with insurers. Proponents also argue a DPC practice’s administrative costs can be reduced because DPC practices set up automated bill payments, often on a monthly basis.
Advocates compare DPC services to those provided in employer-sponsored onsite clinics, in that employees can access primary care at no or reduced office visit fees. Proponents also argue that DPC practices’ economic incentives are aligned with the long-term health of patients, and as a result preventive care gets more emphasis.
Opponents argue that DPC arrangements have certain key limitations.
- While the ACA allows DPC to be a covered benefit, the law also requires DPC practices to be part of a secondary qualifying health plan that covers the full ACA essential benefits if plans including DPC are offered in the health care marketplace.
- DPC plans can be more expensive in the long term for consumers who purchase this care for themselves since DPC payments are not counted towards deductibles, potentially resulting in higher out-of-pocket costs for catastrophic and hospital service costs since deductibles might not have been met if these services are needed.
- Because primary care physicians see fewer patients under the DPC model, increasing DPC popularity could impact overall access to providers.
What Happened Last Legislative Session?
During the 2017-2018 legislative session, Rep. Joe Sanfelippo (R-New Berlin) introduced a bill that would have defined DPC in Wisconsin. The bill would have exempted DPC providers from state insurance regulations but would have enabled the Department of Health Services (DHS) to investigate complaints. Finally, the bill would have required DHS to allow Medicare, Medicaid or BadgerCare recipients to use DPC. The bill passed in the Assembly but failed to pass in the Senate.
After the bill failed to make it through both houses of the Legislature, legislators formed a study committee to shape recommendations that would inform future DPC policy. The committee did not, in the end, recommend any legislation but agreed that DPC is a positive part of the health care system and that the Group Insurance Board should explore DPC for state employees. Relevant information on the study committee can be found here.
What is the Future of DPC in Wisconsin?
Rep. Sanfelippo helped reintroduce the bill this session. This bill is similar to last year’s version in that it defines DPC and exempts DPC from insurance law. However, it differs in that it does not mention DHS investigative authority, nor does it mention Medicaid recipients. In February, companion bills were referred to the Senate Committee on Health and Human Services (SB-28) and the Assembly Committee on Small Business Development (AB-26).
What Does this Mean for The Alliance?
The growing national conversation on DPC is elevating the importance of high-quality, high-value primary care to good health outcomes. The Alliance will continue to watch how the state chooses to regulate DPC to assess the effects of these policy choices on the overall health care landscape. For more information, visit WisContext’s article How Should Wisconsin Regulate Direct Primary Care?
- Learn more about high-value primary care.
- Read about the role for employers in “Moving Upstream in Health Care“.
- Looking Upstream to Change the Cost and Outcomes of Care.